State Abortion Policy and Moral Distress Among Clinicians Providing Abortion After the Dobbs Decision

This survey study assesses moral distress scores among abortion-providing clinicians practicing in states with restrictive vs protective abortion policies following the Dobbs v Jackson Women’s Health Organization Supreme Court decision.


Introduction
The US Supreme Court's decision on Dobbs vs Jackson Women's Health Organization eliminated federal protections for abortion, leaving states with independent regulatory authority.Since the decision, abortion is almost entirely banned in 14 US states.In at least 11 additional states, abortion is severely restricted. 1 Clinicians could face new legal and civil penalties for providing abortion, including felony charges and loss of medical license. 2 In many states with abortion bans, the list of exceptions is narrow and confusing, with few or no exceptions for maternal health or life endangerment. 3,4In this context, clinicians may increasingly find themselves facing a difficult dilemma: either fail to provide appropriate, conscience-driven medical care or put themselves in legal and professional jeopardy.[7][8] The concept of moral distress in health care originates from discussions with nurses over care that they are expected to provide but they ethically oppose. 9,10While early definitions of moral distress focused on negative claims of conscience (or when individuals object to care required of them, such as overtreatment during end of life), the definition has since broadened to include positive claims of conscience, or the inability to provide the care that one feels morally compelled to provide.In this context, moral distress has direct applications to abortion-providing clinicians facing abortion bans. 11,12Prolonged exposure to moral distress without resolution can lead to moral injury.
[15][16] Since the Dobbs decision, commentaries and qualitative studies have raised concerns about increasing moral distress among clinicians. 6,7,17We aimed to quantify moral distress among clinicians providing abortion following the Dobbs decision and to assess differences by state-level abortion policy.We hypothesized that clinicians in states that restrict abortion would report higher moral distress scores compared with clinicians in states that protect abortion.We also aimed to identify additional factors that are positively or negatively associated with moral distress.

Study Setting and Participant Recruitment
This survey study followed the American Association for Public Opinion Research (AAPOR) reporting guideline. 18The institutional review board at The Ohio State University approved this study.Electronic informed consent was obtained before completion of the anonymous, online survey.
Participants who completed the survey were eligible to receive a $10 gift card.
From May to December 2023, we recruited clinicians (physicians, advanced practice clinicians, and nurses) whose practice included abortion care to complete a 30-item online survey querying personal demographics, practice characteristics including state of practice, and the experience of

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State Abortion Policy and Moral Distress Among Clinicians Providing Abortion moral distress related to their abortion care practice (eAppendix in Supplement 1).We included clinicians providing abortion care at the time of the survey and those not currently providing but who had provided abortion care between May 2021 and June 2022 (the year prior to the Dobbs decision).
We excluded nonclinicians and clinicians who reported providing abortion care neither at the time of the survey nor in the year prior to the Dobbs decision.
We recruited participants through email using professional listservs tailored toward clinicians who provide abortion.We also used snowball sampling by encouraging respondents to forward recruitment materials to their colleagues who could meet inclusion criteria.Prospective participants completed an electronic prescreening eligibility questionnaire.
Moral distress could be associated with race and ethnicity 6 ; therefore, we asked participants to self-report these variables.Race categories included African American or Black, Asian, White, and multiple races selected.Ethnicity categories were Hispanic or Latinx and not Hispanic or Latinx.

Sample Size
The number of individual clinicians providing abortion in the US is challenging to measure.In their 2020 Abortion Provider Census, the Guttmacher Institute (a research and policy organization that uses evidence to advance sexual and reproductive health) identified 1603 health care facilities nationally that provided abortion but did not assess the number of individual clinicians. 19,20Given these limitations on defining a sampling frame, our recruitment goal was more general: to collect a purposive sample of abortion-providing clinicians, including respondents from states with both low and high numbers of abortion clinics.Using the 2020 Abortion Provider Census, we divided states into low clinic number (<15 clinics statewide) and high clinic number (Ն15 clinics statewide).Around 80% of abortion clinics were in states with high clinic numbers.To capture a wider range of experiences, we aimed to oversample clinicians from states with a low clinic number, with a plan to continuously assess and target recruitment such that the sample composition remained at or above 20% of respondents from states with a low clinic number.

Dependent Variables Moral Distress Thermometer
We examined moral distress as our dependent variable.All participants completed a modified version of the Moral Distress Thermometer (MDT), a single-item scale to measure moral distress.Scores range from 0 (none) to 10 (worst possible), with written descriptors to anchor degree of distress (Figure 1).The MDT is a validated psychometric screening tool originally used to measure moral

Moral distress thermometer
Derived from Wocial and Weaver. 212][23] Our modification to the instrument is consistent with instrument construction: it includes the original definition and rating scale and asks respondents to reflect on their clinical practice in a specific context. 21

Self-Reported Changes in Moral Distress After Compared With Before the Dobbs Decision
In addition to the MDT, the survey asked clinicians to report whether they had experienced more, less, or the same levels of moral distress after compared with before the Dobbs decision.We analyzed these responses to understand self-reported changes in moral distress among all respondents.

Primary Independent Variables
The first independent variable that we examined was whether a respondent's reported US state of abortion care practice was restrictive or protective according to the Guttmacher Institute's classification (state policy category). 1To assess state of abortion practice, we asked clinicians to select 1 US state of practice to keep in mind when answering questions related to moral distress.
Because abortion-providing clinicians can practice in more than 1 state, we allowed participants to provide moral distress responses for up to 3 US states.We used the Guttmacher Institute's abortion policy categories as of December 2023 (when the survey closed) to characterize each state.The Guttmacher classification groups US states into 1 of 7 categories, from "most restrictive" to "most protective," based on abortion policies currently in effect. 1 We collapsed the 7 categories into 2: restrictive (includes "most restrictive," "very restrictive," and "restrictive") and protective (includes "most protective," "very protective," and "protective").We included the middle category "some restrictions/protections" in the protective category.
The second independent variable that we examined was whether a respondent practiced in a state with a large change in abortion volume after the Dobbs decision, classified as a surge, loss, or stable (neither surge nor loss) state.We constructed these categories based on WeCount, a national abortion reporting effort. 24WeCount defines surge states as those with the largest cumulative increase in total number of abortions provided in the 12-month period following the Dobbs decision (Illinois, Florida, North Carolina, California, and New Mexico) and defines loss states as those with the largest decline in total number of abortions during the 12-month period following the Dobbs decision (Texas, Georgia, Louisiana, Wisconsin, and Alabama). 24We examined associations of surge, loss, and stable state classification both with and without California given that California is a surge state but experienced only a 4% increase in overall abortion volume while other surge states experienced an 18%-32% increase in abortion volume following the Dobbs, as changes in relative volume may drive clinician experiences of moral distress.

Statistical Analysis
We first assessed respondent moral distress scores descriptively overall and by our main independent variables, demographic characteristics, and abortion practice characteristics.We assessed differences in median moral distress using Kruskal-Wallis tests (Table 1).
We then constructed unadjusted and adjusted negative binomial regression models to estimate associations between (1) state policy category (restrictive or protective) and MDT scores and (2) post-Dobbs state change in abortion volume category (surge, loss, or stable) and MDT scores.We accounted for clustering by respondent, as participants could complete MDTs for multiple states of practice.We selected negative binomial regression models to address observed overdispersion in the outcome, a count variable (MDT score).
In adjusted models, we included covariates that may be associated with either state policy category or state change in abortion volume category and with MDT score.These included (1) role in health care (physician, nurse, or advanced practitioner), as state laws can prohibit advanced practice clinicians from providing abortion care; (2) health care setting (free-standing abortion clinic vs other), as state laws can restrict hospital-based abortion care, leaving the majority of abortion care to occur We conducted 2 sensitivity analyses altering how we coded state policy category to assess the robustness of our findings.First, during the time of the survey, the Guttmacher Institute's categorization of some state abortion policy changed.Kansas moved from restrictive to protective.
We reanalyzed the data with Kansas as protective.Second, we moved the Guttmacher category "some restrictions/protections" into the restrictive category.
We conducted all analyses using Stata, version 18 (StataCorp LLC).A priori, we set the type 1 error rate (α) to 0.05, and declared P < .05 to be statistically significant.

Sample Characteristics
We do not know how many individuals received the survey, as we recruited through listservs that protect their members' identities and through snowball sampling.

Self-Reported Changes in Moral Distress After Compared With Before the Dobbs Decision
For each MDT, the majority of respondents (275 [78.1%]) reported experiencing more moral distress since the Dobbs decision.For only 15 MDTs (4.3%), respondents reported experiencing less moral distress.

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State Abortion Policy and Moral Distress Among Clinicians Providing Abortion

Discussion
This study found that since the Dobbs decision, a sample of clinicians providing abortion nationally have experienced median moral distress scores between "uncomfortable" and "distressing" on the MDT.Clinicians in states with a restrictive abortion policy reported MDT scores more than twice as high as clinicians in states with a protective policy ("intense" vs between "mild" and "uncomfortable").Most MDTs (78.1%) indicated that abortion-providing clinicians experienced more moral distress after compared with before the Dobbs decision.Factors positively associated with moral distress included being a physician, practicing in free-standing abortion clinics, no longer providing abortion care since the Dobbs decision, practicing in loss or surge states, and practicing in the Southwest, Southeast, or Midwest.
To our knowledge, this study is the first to quantitatively measure moral distress among clinicians providing abortion in any context, including since the Dobbs decision; to compare moral distress across state policy environments; and to include midlevel clinicians and nurses.Our study's quantitative outcomes compliment the results of the qualitative study by Sabbath et al 17 that described the experience of 54 obstetrician-gynecologists practicing under abortion bans.In that study, among interviewees, 93% reported moral distress, or the experience of "not follow [ing]   clinical standards due to legal constraints." In our study, individuals no longer providing abortion care and individuals practicing in loss states had higher moral distress scores compared with those still providing abortion care and those practicing in surge or stable states, respectively.6][27] Individuals who previously provided abortion and who may continue to interact with patients seeking abortion care that they can no longer provide may uniquely experience moral distress or moral injury.
Our findings indicated elevated moral distress among some clinicians in protective states.Such clinicians may experience uncertainty regarding the national abortion legal climate, fears for patients and colleagues in restrictive states, and institutional rather than state restrictions.We also found high moral distress among clinicians in surge states (states often categorized as protective), which may reflect increasing patient volumes, resource scarcity, and witnessing pregnant patients traveling from out of state after being prevented from receiving necessary medical care.Moral distress has been identified in similar health care contexts, including during the COVID-19 pandemic when health care workers faced worsening outcomes, resource shortages, and lack of supportive policies. 11,28me may argue that moral distress could be elevated in abortion-providing clinicians at baseline.However, in a previous survey, abortion-providing clinicians reported higher compassion satisfaction, or pleasure from doing their job well, compared with other health care clinicians. 29High compassion satisfaction indicates high levels of pride in the work that one provides.Moreover, regardless of baseline, we found that most clinicians in this survey study reported feeling more moral distress after compared with before the Dobbs decision.
Clinicians who are members of racially and ethnically marginalized communities may be at particular risk of moral distress. 6While we found no association between race or ethnicity and MDT scores, the sample included few Black and Hispanic or Latinx respondents.Similarly, previous commentaries have focused on moral distress among trainees. 5,6We found no such association, although the sample included few trainees.

Implications
5][16] With most of the sample (93.2%) providing some nonabortionrelated health care, clinician attrition has implications for the broader maternal health workforce.
Before the Dobbs decision, states that restricted abortion had higher rates of maternal mortality compared with those that did not. 30If moral distress contributes to reproductive health care clinician attrition in abortion-restrictive states, clinician shortages in these states could grow, widening statelevel disparities in pregnancy-related mortality.
Recent commentaries have proposed encouraging compassion to mitigate the effects of moral distress among clinicians since the Dobbs decision. 6Compassion and resilience training have proven to be successful interventions to reduce moral distress in other health care contexts. 313][34] However, our findings indicate the need to look beyond expecting individuals to build compassion and resilience given the widespread nature of moral distress in the abortion-providing workforce.

Limitations
This study has limitations.Our survey carried the risk of selection bias, as clinicians responding to our survey may have been more likely to have experienced moral distress compared with those not participating.To our knowledge, no pre-Dobbs assessment of moral distress among abortionproviding clinicians exists for comparison.We could not calculate our response rate given the challenges in defining the sample population, the use of recruitment through listservs that protect

Conclusions
In this purposive, national survey study of clinicians providing abortion, moral distress was elevated among all clinicians and was more than twice as high among clinicians practicing in states that restrict abortion compared with those in states that protect abortion.These findings suggest that structural change that addresses bans on necessary health care is needed at institutional, state, and federal policy levels, including minimizing institutional barriers, bolstering state protections through abortion shield laws, and codifying federal protections for abortion.

Figure 1 .
Figure 1.Moral Distress Thermometer and Prompt

Figure 3 .B
Figure 3. Median Moral Distress Thermometer (MDT) Score by State With Guttmacher Institute Abortion Policy Map State abortion policies in effect as of December 15, 2023B

Table 1 .
Median MDT Scores by Participant Characteristics (continued) Of those who consented but did not provide MDTs (36 total), 18 did not provide state of practice.Of the 18 respondents who provided state of practice but no MDT, 5 (27.8%) practiced in at least 1 restrictive state.We have no demographic information on respondents not meeting eligibility or providing consent.

Table 2 .
Unadjusted and Adjusted Negative Binomial Models Examining the Association of Abortion Policy Context and Change in Abortion Volume Since the Dobbs Decision With Levels of Moral Distress b Association of change in abortion volume since the

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Abortion Policy and Moral Distress Among Clinicians Providing Abortion Downloaded from jamanetwork.combyguest on 08/26/2024 members' identity given the sensitive nature of abortion provision, and the use of snowball sampling.Future studies including nurses, trainees, and clinicians with greater racial and ethnic diversity are necessary to illuminate differences across these roles and identities and would improve the generalizability of findings.We chose to include only clinicians whose professional standards are guided by a formal code of medical ethics; future research should include administrative staff and medical assistants.The MDT may not capture the nuances and changing nature of moral distress.While the MDT can indicate relative moral distress, no specific number has been validated as a predictor of burnout or attrition.Our modified MDT queried moral distress "as a result of the Dobbs decision," which may have overly primed responses.Also, the Guttmacher Institute and WeCount categories of state-level restrictiveness do not reflect institutional restrictions; individuals experiencing moral distress based on institutional restrictions could have been misclassified.Moral distress among clinicians providing abortion should also be studied using qualitative methods.